Conjunctival Argyrosis

Key points at a glance

Highlights of this disease

• Conjunctival argyrosis (ocular argyrosis) is a condition in which silver is deposited in ocular tissues due to chronic exposure to silver-containing compounds.
• Occupational exposure (jewelry making, photographic development, dentistry) and long-term use of silver-containing eye drops or cosmetics are the main causes.
• The conjunctiva turns bluish-gray, and gray-green to golden deposits appear in the deep corneal layer (Descemet’s membrane).
• It usually does not cause visual impairment, but decreased contrast sensitivity in dark conditions has been reported.
• Deposited silver is irreversible, and treatment mainly focuses on prevention by avoiding exposure.

1. What is conjunctival argyrosis?

Argyrosis is derived from the Greek word “argyros” meaning silver ¹⁾. It is a condition in which silver deposits in body tissues due to chronic exposure to silver-containing compounds, and when it occurs in the eye, it is called ocular argyrosis.

Historically, since the 17th century, large amounts of silver were used medically to treat diseases such as epilepsy. Currently, argyrosis due to treatment is rare, but cases have been reported from occupational exposure (photography, jewelry making, dentistry), silver-containing eye drops, colloidal silver, and cosmetics such as eyelash dyes ^1,2).

It is one of the diseases to consider in the differential diagnosis of conjunctival pigmented lesions.

2. Main symptoms and clinical findings

Subjective symptoms

Ocular argyrosis is usually asymptomatic. However, decreased contrast sensitivity under scotopic conditions has been reported, suggesting involvement of silver deposition in the retina ³⁾.

Clinical findings (findings confirmed by a physician)

• Conjunctival discoloration: The conjunctiva turns bluish-gray. In the nasal conjunctiva where tears accumulate, it gradually becomes blackish. Pigmentation may also be observed in the upper eyelid, eyelid margin, and caruncle.
• Corneal deposits: Gray-blue, gray-green, or golden deposits are seen in the deep corneal layer (near Descemet’s membrane). They are distributed in a ring shape inside the limbus, with clear borders.
• Other deposition sites: Silver deposits may also be found in Bowman’s membrane, the lens, and Bruch’s membrane.

Q Does argyrosis affect vision?

A

It usually does not cause visual impairment. However, decreased contrast sensitivity under dark conditions has been reported, and regular ophthalmic examinations including contrast sensitivity are recommended for patients with chronic silver exposure. If severe corneal deposits cause vision loss, corneal transplantation may be considered.

3. Causes and Risk Factors

Ocular argyrosis is caused by repeated exposure to silver-containing compounds. The forms of exposure are broadly classified as follows.

• Occupational exposure: Photographic processing, jewelry making/silver polishing, dental workers, etc. There is a direct correlation between exposure duration and the degree of pigmentation.
• Medications: Long-term use of silver-containing ophthalmic preparations such as silver nitrate eye drops and Argyrol (silver protein). Their use has decreased nowadays.
• Cosmetics: Long-term use of eyelash dyes containing silver nitrate. Can cause permanent silver deposition.
• Radiation therapy: Subconjunctival silver deposition has been reported after ruthenium-106 brachytherapy (with a silver-coated core) for choroidal malignant melanoma.
• Acute exposure: Direct splashing of silver into the eye due to chemical explosions, etc.

Prevention of Argyrosis

• In occupations involving silver, always wear protective goggles.
• Use of eyelash dyes containing silver nitrate carries a risk of long-term silver deposition. Check the ingredients.
• If you are prescribed silver-containing eye drops, have regular eye examinations.

4. Diagnosis and Differential Diagnosis

Diagnosis

Ocular argyrosis is a clinical diagnosis based on a history of silver exposure and slit-lamp examination.

The following have been reported as ancillary imaging tests.

• Anterior segment optical coherence tomography (AS-OCT): Depicts hyperreflective deposits in Bowman’s layer and Descemet’s membrane, useful for noninvasive quantitative assessment ⁴⁾.
• In vivo confocal microscopy: Visualizes reflective deposits at the cellular level in Descemet’s membrane, Bowman’s layer, and corneal stroma, useful for evaluating depth distribution ³⁾.

Differential Diagnosis

The following are differentiated as pigmented conjunctival lesions.

• Conjunctival nevus: Flat to slightly elevated pigmented lesion. Appears in childhood and often accompanied by cysts.
• Primary acquired melanosis (PAM): Unilateral flat brown pigmentation. Carries risk of malignant transformation.
• Conjunctival malignant melanoma: Elevated nodular pigmented lesion. Often arises from PAM or de novo.
• Other metal deposits: Differentiation from iron deposits (siderosis), copper deposits (Kayser-Fleischer rings), and gold deposits (chrysiasis) is necessary.

Q How to differentiate when conjunctival pigmentation is observed?

A

Argyrosis presents with diffuse bluish-gray discoloration, and a history of silver exposure is important. Conjunctival nevus is localized with cysts, while PAM presents as unilateral brown patches. For localized elevated lesions, malignant melanoma must be excluded. AS-OCT and in vivo confocal microscopy are useful for ancillary diagnosis.

5. Pathophysiology

Long-term exposure to silver-containing compounds leads to deposition of silver in ocular tissues. Histologically, deposits have been confirmed in the conjunctival epithelium, basement membrane, superficial substantia propria, Descemet’s membrane, lens, and Bruch’s membrane.

In the cornea, silver deposits are mainly concentrated in Descemet’s membrane and Bowman’s layer. Deposits are also found in the deep corneal stroma, distributed in a ring shape inside the limbus.

Silver deposits can also cause blue to bluish-gray discoloration of the skin (argyria), and ocular symptoms may appear as part of systemic argyrosis.

6. Management and Prognosis

Management

Management of ocular argyrosis primarily focuses on prevention and avoidance of exposure.

• If asymptomatic, observation is recommended.
• If there is occupational exposure to silver, instruct the use of protective eyewear.
• Discontinue use of causative silver-containing medications or cosmetics.
• In cases of severe corneal deposits causing visual impairment, corneal transplantation may be considered.

Deposited silver is not naturally removed from tissues, and the discoloration is irreversible.

Prognosis

The impact on vision is usually mild, and the prognosis is good. However, decreased contrast sensitivity in dark conditions may occur, so regular ophthalmic examinations are recommended for patients with silver exposure.

Q Can deposited silver be removed?

A

Silver deposited in tissues is irreversible, and there is no pharmacological method for removal ¹⁾. Corneal transplantation may be considered in cases of severe corneal deposits causing visual impairment, but usually observation is sufficient. The most important measure is prevention through avoidance of exposure.

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7. References

1. Fernández Mora N, Boto De Los Bueis A. Ocular argyrosis. Oman J Ophthalmol. 2023;16(2):373-376.
2. Dudeja L, Dudeja I, Janakiraman A, Babu M. Ocular argyrosis: a case with silver deposits in cornea and lens. Indian J Ophthalmol. 2019;67(2):267-268.
3. Sarnat-Kucharczyk M, Pojda-Wilczek D, Mrukwa-Kominek E. Diagnostic methods in ocular argyrosis: case report. Doc Ophthalmol. 2016;133(2):129-138.
4. He X, Simmons NL, Wozniak RAF. Anterior segment optical coherence tomography in ocular argyrosis. Cornea. 2020;39(11):1433-1435.